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This is a case of Clostridioides (Clostridium) difficile colitis with typical pseudomembranes on the colonic mucosa.  Elderly and nursing home patients are risk factors. We should take biopsies and ask for faecal sample (GDH and /or culture for toxigenic C.diff) because pseudomembrane rarely can have other causes (Staphylococcus aureus, CMV, radiation, ischemic, chemotherapy)

Patient does not meet the definition of Severe (>15000 leucocytes or deranged Creatinin) or fulminant (hypotension, septic shock, megacolon)

Most guidelines no longer recommend Metronidazole for C.diff as first line unless no other alternative available.  Despite ACG recommends either Vancomycin or Fidaxomicin as first line, (Fidaxomicin is more expensive) the European guidelines recommend Fidaxomicin over Vancomycin (Vancomycin is a perfect acceptable good choice , however despite both curing the infection in about the same rates (76.2% vs 70.5%),  lower recurrence rates with fidaxomicin are described (8.3% vs 32.6%) which could justify its higher cost.

Audit C score has 3 questions and if score is 5 or more, should prompt the full AUDIT of 10 questions.  Most questions ask about the past year alcohol habits. In a full AUDIT , any 15 or above represents high risk of alcohol dependence.

Number 3 is correct but not universal. A standard drink in US contains 14g, 10g in many EU countries and 8g in the UK. EASL advices to standardise to 10g (1 unit) but this is down to the individual countries. https://auditscreen.org/

Although Adenocarcinoma is the most rapidly growing esophageal cancer, still the most common type of esophageal cancer worldwide is esophageal squamous cell carcinoma (SCC). The highest-risk area, called the “esophageal cancer belt,” includes portions of northern Iran, southern Russia, central Asian countries, and northern China, where SCC dominates all cases by 90%. These are very dense populated areas.

However, in Western countries like the United States, esophageal adenocarcinoma has become more common in recent decades, particularly in the lower part of the esophagus and the gastroesophageal junction (GEJ). This increase in adenocarcinoma is often linked to conditions like Barrett esophagus and gastroesophageal reflux disease (GERD).

In summary:

• Worldwide: Esophageal squamous cell carcinoma (SCC) is the most common.
• Western countries (US and Europe): Esophageal adenocarcinoma has surpassed SCC in incidence.

<2cm visible lesion without deep invasion: Offer EMR first and then ablation for Barretts eradication if lesion has been cured

Low grade dysplasia is a difficult diagnosis and should be always  confirmed by at second endoscopy and ideally by two pathologist (sometime LGD is actually downgraded to non displasia , or sometimes when reviewed can be upgraded to HGD)

HGD, on the contrary, does not necessarily need repeating endoscopy but always needs to be confirmed by a expert GI pathologist.  If any doubt, it is always reasonable to repeat endoscopy.

Patients with early-stage esophageal adenocarcinoma need treatment depending on many factors ( EMR, ESD, surgery or Radio-chemotherapy , discuss in the MDT)

If Check the guidelines

Difficult question, but summarizes the (sometimes) difficult scores.
Montreal classification is easy - A for Age  L for location and B for phenotype.  There is ileal and colonic involvement so it is L3 (Ileocolonic) Small p is added when it is perianal disease (abscesses, ulcers or fistulae , but not skin tags or fissures)

The HBI takes into account the general well being , Abdominal pain   Number of liquid stools per day, Abdominal mass and extrainestinal Complications ( arthralgia, uveitis, erythema nodosum, aphthous ulcers, pyoderma gangrenosum ,anal fissure , new fistula or abscess)

<5 Remission   5-7 Mild disease  8-16 Moderate disease  >16 Severe disease

Her score is 9 (Moderate) But this could be guessed based on her level of pain, stools and absence of systemic inflamamtory reponse.

Check the HBI score

Synthetic liver function test include Albumin and clotting.
High bilirubin is part of the definition of liver impaired function

ALT is a marker of liver damage or insult, but does not relate to how well the liver is functioning.

See AASLD  and BSG guidelines

Difficult case. In this patient, option A is false- This is a very early stage ≤2cm (BCLC 0)

HCC requieres always an individualised treatment. Knowing that patient is fit and wihtout portal hypertension, he could be amenable for resection. However ablation has been proved to be as effective as surgery with less adverse events, so it would probably be indicated in such as small lesion as first line. The bigger the lesions, the less efficacious ablation is as can leave tumoral tissue untreated. In this case, transplant  certainly could be considered but would not be an ideal first line option as still is <2cm and Child A does not warrant the inclusion in list.

If this HCC was between 2-5cm, treatment could be trasplant (however Child A has per se no indication for transplant, being in the list with modify MELD can be tricky and has risk of tumour progression) surgical resection or ablation, based on radiological features , patient background and preferences

If multifocal HCC,  transplant is ususally the recommended 1st line therapy, whereas TACE/SIRT would be an option in non transplant candidates, unless the lesions are in the same lobe and accesible, in which case occasionally surgical resection can be offered.

If mass>7cm, this surpasses even the Expanded Milan criteria, and we know the risks of HCC invasion, recurrence and mortality after transplant are too high, therefore TACE/ SIRT/ Stereotactic resection or surgical resection are options based on patients features.

High Amplitude propagating contractions (HAPC)

• HAPC, Defined by high amplitude (variable threshold among studies) and presence of propagation; amplitude is higher in the prepped than unprepped colon
•  from 50-100, can reach up  to 200 mm Hg, they last 20 to 30 seconds, approximately 6 times a day, with a range of 2 to 24 daily.
• Occur spontaneously, in response to pharmacological agents or colonic distention
• Increase upon awakening, are much more common during the day, and increase after meals
• A majority originate in the proximal colon; most do not propagate beyond the midcolon and fewer than 5% reach the rectum
• Can transfer colonic contents over long distances, can be associated with internal anal sphincter relaxation, and can precede defecation

Low amplitude (Haustral Contractions)

• Slow, segmenting movements that further mix chyme.
• About every 30 minutes.
• (5 to 40 mm Hg) 3 seconds
• Occur in haustra: small pouches caused by the teniae coli (longitudinal smooth muscle ribbons that run along outside the entire length of the colon). Because they are shorter than the large intestine, the large intestine tucks between the teniae and form sacs
• Primarily occur in ascending and transverse colons.
• Produced by contractions of smooth muscle layer

Both the low- and high-amplitude contractions are promoted by physical exercise as well as by emotional stress.

It is known that HAPC reduce  over time in elderly patients, and also are notoriously reduced in frequency in those wih chronic constipation. Opposingly they are increased in diarrhoea type IBS.  Low amplitude are worse understood, and despite increasing with age, they do not usually change the transit time.

Source

Source 2

Anatomy and Physiology of the Pelvic Digestive Organs
Ursula Szmulowicz MD, in
Posterior Pelvic Floor Abnormalities
, 2011

Check the guidelines

Even in 2019, 38.9% of the HCC- liver transplant  had Hepatitis C etiology (vs 24% NASH and 16.3% ALD) . This is completely different in patients without HCC (the majority of liver transplant candidates, which only 7% had hepatitis C , 28% NASH and the leading cause with 37.7 %  was ALD.  https://doi.org/10.1016/j.cgh.2020.05.0